Provider Demographics
NPI:1679762991
Name:VANN, GRADY MITCHELL (LPC LICENSED PROFESS)
Entity type:Individual
Prefix:MR
First Name:GRADY
Middle Name:MITCHELL
Last Name:VANN
Suffix:
Gender:M
Credentials:LPC LICENSED PROFESS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3441
Mailing Address - Street 2:
Mailing Address - City:HUEYTOWN
Mailing Address - State:AL
Mailing Address - Zip Code:35023-0441
Mailing Address - Country:US
Mailing Address - Phone:205-260-5138
Mailing Address - Fax:205-533-8896
Practice Address - Street 1:2109 DARLINGTON ST
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226
Practice Address - Country:US
Practice Address - Phone:205-260-5138
Practice Address - Fax:205-533-8896
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2363101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional